Date Published: January 31, 2019
Publisher: Public Library of Science
Author(s): Susan Dierickx, Julie Balen, Chia Longman, Ladan Rahbari, Ed Clarke, Bintou Jarju, Gily Coene, Jasmine Fledderjohann.
In many Sub-Saharan African countries, women with infertility search relentlessly for treatment. Guided by the Partners for Applied Social Sciences model for health seeking behaviour and access to care research, this study aims to understand the health seeking behaviour of women with infertility in the West Coast region of The Gambia and the influence of aetiological beliefs on health seeking paths.
A qualitative approach was used to generate both primary and secondary data for thematic analysis. The data collection methods included in-depth interviews (36), observations (18), informal conversations (42), group discussion (7) and made use of pile-sorting exercises. Sources of secondary data included government and non-governmental reports and media outputs.
The health seeking approaches of women living in both rural and urban areas were extremely complex and dynamic, with women reporting that they looked for biomedical treatment as well as seeking indigenous treatment provided by local healers, sacred places and kanyaleng groups. While treatment choice was related to the perceived aetiology of infertility, it was also strongly influenced by the perceived effectiveness of the treatment available and the duration of the fertility problems. Other relevant factors were the affordability, accessibility and availability of treatment and respondents’ family and social networks, whereby access to the biomedical health sector was strongly influenced by people’s socio-economic background.
On the basis of this analysis and our wider research in the area, we see a need for health authorities to further invest in providing information and counselling on issues related to infertility prevention and treatment. The availability of locally applicable guidelines for the management of infertility for both men and women at all levels of the health system would facilitate such work. In addition, the public sphere should provide more space for alternative forms of social identity for both men and women.
Infertility is a global reproductive health problem affecting 48.5 million couples worldwide . Especially in Sub-Saharan Africa (SSA) many people are confronted with primary infertility (1.9%) and there continues to be a high rate of secondary infertility (11.6%). However, there is no consistent clinical, epidemiological and demographical definition of infertility nor a common denominator to measure infertility [1–3]. Moreover, clinical, epidemiological and demographical conceptualizations of infertility, subfertility, miscarriage and stillbirth are not always congruent with people’s own understanding of these events [4–10]. Therefore, this study starts from women’s lived experiences and perceptions of infertility and includes women that consider themselves to have fertility problems, regardless of the duration of these problem or whether they relate to primary or secondary infertility.
To comprehensively delineate the complexity of the data, we present the findings of the thematic analysis of the data according to the PASS model in five sections: (i) illness perception and explanatory models; (ii) medical pluralism; (iii) social values; (iv) access to treatment and resource seeking and (v) evaluation (Fig 1) .
This qualitative study aimed to understand the health seeking behaviour of women with infertility and the influence of aetiological beliefs on health seeking paths. To the knowledge of the authors, this is the first study exploring the health seeking of women with infertility using the PASS-model as basis for qualitative enquire (Fig 1) . This model allowed for a detailed and systematic analysis of the different aspects of health seeking behaviour relevant to women living in the West Coast region of The Gambia. This study showed that health seeking behaviour is strongly influenced by the limited availability and affordability of biomedical diagnosis and treatment, people’s social network and to a lesser extent by varying illness perceptions. In addition, this study contributes to the few earlier qualitative studies looking at the influence of social positions on the lives of women with infertility in low-and middle-income countries [96,97].
The PASS-model presents a comprehensive framework for health planners and researchers interested in health-seeking behaviour and access to care . The model places health seeking behaviour in a broader socio-political, cultural and economic context and identifies and relates a wide range of factors that might guide people’s health seeking behaviour. Guided by the PASS-model this study showed that health seeking for infertility in The Gambia cannot be understood in isolation from the social, political, and economic structures within which it is embedded, or without reference to aetiological beliefs. However, attributing delay, adherence and treatment choice solely to ‘traditional’ beliefs or a lack of knowledge does not represent how women make pragmatic choices in their search for health care given the context of structural inequalities. This analysis highlights that attention should be directed to open a public dialogue on infertility, as well as on the role of men when it comes to infertility. We call for health authorities to invest in providing information and counselling on issues related to infertility prevention and treatment, and draw up guidelines for the management of infertility at all levels of the health system. Lastly, while the authors would like to argue that couples have the reproductive right to access infertility treatment, more room should be created in the public sphere for alternative forms of social identity for both men and women.